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At least 541 records · Page 30Linked to original sources
PubMed2005

Strengthening Medicare: will increasing the bulk-billing rate and supply of general practitioners increase access to Medicare-funded general practitioner services and does rurality matter?

BACKGROUND: Recent increases in the bulk-billing rate have been taken as an indication that the Federal government's Strengthening Medicare initiative, and particularly the bulk-billing incentives, are 'working'. Given the enduring geographic differences in the supply of general practitioners (GPs) it is timely to reconsider the impact that this increase in the provision of 'free care' will have on access to Medicare-funded GP services in rural and urban areas of Australia. Utilisation has been modelled as two different stochastic processes: the decision to consult and the frequency of consultation. RESULTS: In the decision to consult model the supply of FFS GPs is a more important predictor of utilisation than the bulk-billing rate. Paradoxically the modelling predicts that ceteris paribus increases in either GP supply or the bulk-billing rate appear to have perverse effects in some areas by decreasing utilisation. In the frequency of consultation model, GP density is not a predictor and increasing the bulk-billing rate will unambiguously increase the frequency of consultation across all areas. In both models, the positive impacts associated with changes in supply and cost are constrained outside the inner metropolitan area by reduced geographic accessibility to Medicare-funded GP services. The modelling also shows that people are more likely to consult a GP in areas of high socioeconomic disadvantage, although socioeconomic status is not a predictor of frequency of consultation. CONCLUSION: Bulk-billing rates and the supply of FFS GPs are important features of the Australian health care system that are, potentially, amenable to policy manipulation. The implications of this research are that government policies designed to achieve similarity in these characteristics across geographic areas will not result in equity of access because they fail to address problems caused by geographic inaccessibility in rural and remote areas. Attempting to increase bulk-billing rates in some of these areas may, in fact, reduce access to FFS GP services.

Journal Article↗
PubMed1999

British psychiatry and homosexuality.

BACKGROUND: Opposition to homosexuality in Europe reached a crescendo in the 19th century. What had earlier been regarded as a vice evolved as a perversion or psychological illness. Official reviews of homosexuality as both an illness and (for men) a crime led to discrimination, inhumane treatments and shame, guilt and fear for gay men and lesbians. Only recently has homosexuality been removed from all international diagnostic glossaries. AIMS: To review how British psychiatry has regarded homosexuality over the past century. METHOD: Review of key publications on homosexuality in British psychiatry. RESULTS: The literature on homosexuality reflects evolving theories on sexuality over the past century. The assumptions in psychoanalysis and the behavioural sciences that sexuality could be altered led to unscientific theory and practice. CONCLUSIONS: Mental health professionals in Britain should be aware of the mistakes of the past. Only in that way can we prevent future excesses and heal the gulf between gay and lesbian patients and their psychiatrists.

Attitude of Health Personnel↗
PubMed2003

A randomized, placebo-controlled trial of topiramate in amyotrophic lateral sclerosis.

OBJECTIVE: To determine if long-term topiramate therapy is safe and slows disease progression in patients with ALS. METHODS: A double-blind, placebo-controlled, multicenter randomized clinical trial was conducted. Participants with ALS (n = 296) were randomized (2:1) to receive topiramate (maximum tolerated dose up to 800 mg/day) or placebo for 12 months. The primary outcome measure was the rate of change in upper extremity motor function as measured by the maximum voluntary isometric contraction (MVIC) strength of eight arm muscle groups. Secondary endpoints included safety and the rate of decline of forced vital capacity (FVC), grip strength, ALS functional rating scale (ALSFRS), and survival. RESULTS: Patients treated with topiramate showed a faster decrease in arm strength (33.3%) during 12 months (0.0997 vs 0.0748 unit decline/month, p = 0.012). Topiramate did not significantly alter the decline in FVC and ALSFRS or affect survival. Topiramate was associated with an increased frequency of anorexia, depression, diarrhea, ecchymosis, nausea, kidney calculus, paresthesia, taste perversion, thinking abnormalities, weight loss, and abnormal blood clotting (pulmonary embolism and deep venous thrombosis). CONCLUSIONS: At the dose studied, topiramate did not have a beneficial effect for patients with ALS. High-dose topiramate treatment was associated with a faster rate of decline in muscle strength as measured by MVIC and with an increased risk for several adverse events in patients with ALS. Given the lack of efficacy and large number of adverse effects, further studies of topiramate at a dose of 800 mg or maximum tolerated dose up to 800 mg/day are not warranted.

Adult↗
PubMed2001

Paying for Medicare: benefits, budgets, and Wilbur Mills's policy legacy.

Medicare features an unusually complex financing design. The Hospital Insurance Trust Fund pays for Part A of Medicare (hospital stays), while the Supplementary Medical Insurance Trust Fund finances Part B (doctor visits, outpatient care, and certain home health services). At a time when Medicare policy is generating debate, this article takes a new analytical look at the origins and consequences of the program's peculiar bifurcated structure. Addressing historians of the U.S. welfare state as well as contemporary health policy reformers, the article focuses on the crucial role of legendary Ways and Means Committee chair Wilbur Mills in Medicare's enactment in 1965. The central theme of the article is that fiscal conservatism and a commitment to budgetary restraint constitute important elements of Medicare's original political understanding. Contrary to analysts who argue that Medicare's financing design has produced "perverse" effects, we argue that it has served a valuable social function by encouraging policy makers to confront periodically the costs of one of the largest and fastest-growing federal programs. An argument can be made that Medicare's original division requires modification in order to integrate health care delivery changes of the past few decades. It is crucial, however, for reformers not to lose sight of the policy goals, including fiscal rectitude, that motivated the adoption of Medicare's bifurcated structure in the first place.

Aged↗
PubMed2005

When methods meet politics: how risk adjustment became part of Medicare managed care.

Health-based risk adjustment has long been touted as key to the success of competitive models of health care. Because it decreases the incentive to enroll only healthy patients in insurance plans, risk adjustment was incorporated into Medicare policy via the Balanced Budget Act of 1997. However, full implementation of risk adjustment was delayed due to clashes with the managed care industry over payment policy, concerns over perverse incentives, and problems of data burden. We review the history of risk adjustment leading up to the Balanced Budget Act and examine the controversies surrounding attempts to stop or delay its implementation during the years that followed. The article provides lessons for the future of health-based risk adjustment and possible alternatives.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2002

Using performance indicators to improve health care quality in the public sector: a review of the literature.

Given the increasing importance of performance indicators in current UK health policy, this paper provides a systematic review of empirical and theoretical writings concerning their use to improve health care quality. The paper outlines potential problems and explores how best to derive, implement and use performance indicator data, presenting results thematically. The two principal uses of indicator systems are as summative mechanisms for external accountability and verification, and as formative mechanisms for internal quality improvement. In the UK, the use of performance indicators in assurance and performance management systems has heavily influenced debate over their value. Major problems reported include the potential to undermine the conditions required for quality improvement, perverse incentives and the difficulty of using data to promote change. Technical problems include indicator selection; the availability, validity and reliability of data; confounding; and problems with robustness, sensitivity and specificity. Factors that help in the derivation, implementation and use of indicator systems include clear objectives, involvement of stakeholders in development, and use of 'soft' data to aid interpretation.

Humans↗
PubMed2004

Using performance indicators to improve performance.

The recent introduction of performance assessment within the UK NHS, incorporating numerous performance indicators (PIs) and league tables, has led to health care organisations facing large numbers of targets and a star rating system with associated rewards and penalties. However, there is considerable evidence that using PIs for judgement rather than learning provides perverse incentives and can prove counterproductive. Drawing on earlier PI systems which, supplemented by expert systems, were designed to promote learning and exploration particularly by encouraging analysis of interactions between different indicators, a series of 'mini case studies' is presented. These reveal interesting relationships and suggest explanations for variations in performance, areas worth exploring further and possible approaches to improving performance -- approaches not apparent from individual indicators and league tables. It is concluded that presentation of PIs in a format that encourages exploration and analysis could greatly enhance the potential of the current PIs to improve NHS performance.

Arthroplasty, Replacement, Hip↗
PubMed2001

Routine monitoring of performance: what makes health research and development different?

Increasing attention is being directed to measuring and monitoring the use of health-related R&D funding, partly to justify this expenditure and partly to ensure that R&D effort is directed to achieving the paybacks desired by funders. These paybacks include contributing to knowledge, contributing to R&D capacity, political benefits, benefits to the health service and to patients, and more general economic benefits. This paper addresses the issues that must be considered when designing a routine performance management system for health R&D. Conventional methods of routine performance management are often rendered inappropriate in this context by the intangible and unpredictable outcomes of research, which are heterogeneous across projects and programmes and which can be hard to attribute to particular R&D support. Instead, to be effective in this context, a routine system must combine quantitative and qualitative indicators, utilising information from a number of different sources. The system must achieve acceptable levels (defined by the funder) on each of the following criteria: it must measure those dimensions of payback that are valued by the funder; it must be decision-relevant; it must be consistent with truthful compliance; it must minimise perverse incentives; and it must have acceptable net costs. It is vitally important that the system itself generates a positive payback. We illustrate these issues by outlining a system that might be used to monitor the payback from government-funded R&D.

Financing, Organized↗
PubMed2004

Suicide by a transvestite or sexual asphyxia? A case report.

Autoerotic asphyxial activity may at times result in unexpected death. Although the majority of deaths that occur during autoerotic asphyxial episodes are accidental, the possibility of suicide must always be entertained. In the case presented here, a 22-year-old married male was found hanging by his neck in his bedroom, which was locked from the inside. He was suspended by a 'lungi' (male wrap-around cloth) from the ceiling fan hook in his room, with his feet touching the ground. He was dressed in a brassiere, panties, and silver anklets. There was no evidence of previous perverse behaviour, and investigation disclosed no evidence of previous autoerotic sexual activity, homosexual behaviour, drug abuse or suicidal ideation.

Asphyxia↗
PubMed2003

Is sane management possible in a crazy world?

Most people benefit from healthcare. However, Canadians remain dissatisfied because too often we receive faulty care and delayed care, not supported by evidence. Browman and colleagues relate successful efforts to introduce evidence-based care. They show that strong champions can be effective even in insane environments. The collaborative approach suggested is moving and thoughtful. Sharing between knowledge and financial stewards, including the use of stories, is especially valuable when financial stewardshipis not possible because we lack information about the local outcomes of care. Goodwill between stewards is especially necessary when there are few external incentives to provide excellent care. In healthcare good deeds are punished, not rewarded. Canadian governments fail to regulate healthcare because of the conflict of interest arising when the same group not only regulates care but also functions as insurer, governor, administrator and evaluator. We need radical change to eliminate the perverse incentives and bizarre management practices that bedevil our healthcare system and impede the use of evidence. Fundamental changes in organization and evaluation proposed by the Halifax Chamber of Commerce and the Kirby and Mazankowski committees will help. Separating the functions of insurer, administrator, evaluator and regulator is ethical and necessary.

Canada↗
PubMed2000

Implementing home care in Canada: four critical elements.

While MacAdam proposes a "national approach to home care#8221; the obstacles to this are well known and substantial. They are the likely cost and the limitations of the federal government s role in healthcare. Building on MacAdam's assessment, this paper outlines four problems embedded in the various home-care service delivery models in Canada: the lack of factual client outcome information to support decision-making, the limited client choice of provider, the perverse incentive of fee for service and the bias against the for-profit provider. The paper proposes that the assessment, classification and measurement of outcomes for every recipient of home-care services be standardized using a proven assessment instrument, such as OASIS-B or MDS-HC, by healthcare professionals certified in its use. The resulting information would be captured in a regional database and available for analysis and research. CIHI would be contracted to manage a national database and to fund the training and certification of assessors. The paper proposes a new service delivery and funding model, utilizing standard client outcome information, different roles for regional health authorities and service providers, and a prospective payment mechanism replacing fee for service. A national home care program may be an elusive dream, but that shouldn't stop experimentation, evaluation and improvement.

Canada↗
PubMed2006

The cost of pay-for-performance in healthcare: an alternative view.

George Pink and his colleagues have provided healthcare policy makers with a thorough review of pay-for-performance systems in healthcare. In general, their review suggests that pay-for-performance systems have resulted in few positive, net outcomes for health systems. Among other things, they cite the perverse incentives often generated by these systems, as well as these systems' high design and administration costs. The following article, building on research in economics, sociology and social psychology, extends their discussion by suggesting why healthcare delivery may be a uniquely difficult sector in which to rely on pay-for-performance systems. This article does not intend to shut down discussion of pay-for-performance in healthcare, but instead suggests how we might usefully think about when pay-for-performance is more or less appropriate. This analysis reveals that the healthcare delivery sector has some unique advantages over other sectors and industries.

Australia↗
PubMed2000

Horizontal and vertical healthcare integration: lessons learned from the United States.

Leatt, Pink and Guerriere provide a very rational argument for moving the Canadian healthcare system towards a more integrated model. They suggest that the current system in Canada is a hodge-podge of disconnected parts. The current system is viewed as providing uncoordinated care, with inadequate use of non-medical practitioners, perverse payment incentives for providers, too much focus on treatment of disease, unacceptable wait times for services and related other problems. The authors provide extensive documentation of vital components of a system they envision for Canada, the rationale for adopting an integrated system of services, and conclude by suggesting strategies for achieving integrated healthcare. Change towards the new system would concentrate initially on primary care, using virtual coordination networks at the local level. Innovative needs-based funding methods would ensure that individuals throughout Canada receive necessary services for keeping them healthy.

Canada↗
PubMed1981

Definition and meaning of sexual orientation.

This essay first examines the current discourse on homosexuality and shows how a "gay identity" has been forged within the doctrines and rituals of the gay liberation movement. This substantiation of the gay person is then linked to "the homosexual," created by medicine in the nineteenth century as one piece in a vast mosaic of sexual "perversions." Finally, it is argued that to depict sexuality as fixed, bifurcated states of sexual orientation, and to ignore the fact that erotic preference is labile and interpenetrated by elements of physicality, emotion, and fantasy, is to impede and even to misdirect research.

Female↗
PubMed1986

My gay Antonia: the politics of Willa Cather's lesbianism.

Although Willa Cather's lesbianism has recently been publicly acknowledged, her personal and artistic political decisions about the revelation of her sexual preference have not been explored. Most critics who acknowledge Cather's homosexuality see no traces in her fiction of what Lillian Faderman calls "same-sex love." Because of the political consequences of writing openly about lesbianism in the time that Cather came of age, according to Faderman, "perhaps she felt the need to be more reticent about love between women than even some of her patently heterosexual contemporaries because she bore a burden of guilt for what came to be labeled perversion." While it would certainly have been possible for Cather to live a discreet lesbian life without showing traces of her sexuality in her writing, it is more likely that her sexual preferences are present in her works, particularly in her most autobiographical book, My Antonia, in the character who represents Cather, Jim Burden. The "emptiness where the strongest emotion might have been expected," the relationship between Antonia and Jim, is more understandable when we realize that both Jim Burden and Antonia Shimerda were imagined by Cather as homosexuals whose deep friendship was based on mutual understanding of their oddness in the heterosexual world of 1918.

Famous Persons↗
PubMed1993

Sexuality degree zero: pleasure and power in the novels of John Rechy, Arturo Islas, and Michael Nava.

"Sexuality Degree Zero" explores common themes and formal strategies in the fiction of three prominent gay Chicano writers: John Rechy, Arturo Islas, and Michael Nava. Employing the concept of a politicized textual "pleasure" as theorized by French critic Roland Barthes, the study argues for the political efficacy of aesthetic choices characteristic to the three authors. Analyses of Rechy's use of pornography, of Islas' transgressive use of cultural iconography, and of Nava's use of sexual "perversions" in the context of classic crime fiction, all go to demonstrate the various uses of pleasure in the construction of a doubly marginalized but defiant self and voice in fiction by gay Chicano men.

Acculturation↗
PubMed1995

On the history of biological theories of homosexuality.

Biological theories of homosexuality fit into the discourse on reproduction and sexuality that began in the nineteenth century. They arose in the context of the early homosexual rights movement, with its claim for natural rights, and the psychiatric discussions about sexual perversions. With the classification of homosexuality as a distinct category, homosexuals were excluded from the "normal". Biological theories of homosexuality were attempts not only to explain its causes, but also to maintain the exclusion of homosexuals as the "other". Biological explanations can be categorized as genetic, constitutional, endocrinological, and ethological. On the one hand, biological theories were used in the struggle for homosexual rights. On the other hand, they were used to "cure"e homosexuals. Every theory led to a specific therapy. This paper points out the roots of this thinking, traces the development of various theories, and shows the utilization of biological theories in treating homosexuality.

Female↗
PubMed1995

Homosexuality and the Left in the Netherlands: 1890-1911.

The attitudes of the Dutch socialist left toward homosexuality are examined, drawing upon a wide range of sources. At the end of the nineteenth century, a political debate on prostitution heightened social interest in sexuality in its diverse forms. Medical literature on sexual perversion was another starting point for the growing discussion of homosexuality. These debates were joined by Dutch socialists of divergent opinions. Whereas some of them wanted to acknowledge the right of homosexuals who were born that way to express themselves, only one exceptional author defended the right to homosexual sex. But most socialists were prejudiced against homosexuality and generally endorsed Frank van der Goes's proposal to eliminate homosexual behavior while accepting the notion of an inborn homosexual orientation.

History, 19th Century↗